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moo• e <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 'y <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> Cn{InOn M,� <br /> COMPLETETHIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY I NEW PERMIT G' 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT F-1 4 AMENDED PERMIT O e TEMPORARY SITE CLOSURE Q <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DSA OR FACILITY NAME NAME OF OPERATOR <br /> O / <br /> ADDRESS � NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA TO INDICATE ATE CORPORATION O INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY Q STATE-AGENCYr Q FEDERALdGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O I GAS STATION 2 DISTRIBUTOR q SEIRVADIIAON #OF TANKS AT SITE E.P.A. 1.D.#(apllmaq <br /> 3 FARM A PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> _ 1 c 11 0 at Sop f 2-c,!2! — — <br /> NIGHTS: NAME( AST,FIRST) PHONE#*1TH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> � I PHONE*WITH AREA COD <br /> — <br /> IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED) <br /> NAME rn� (( CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box blralbaa E:I INDIVIDUAL O LOCAL AGENCY 0 STATE AGENCY <br /> KT Q O CORPORATION E�3 PARTNERSHIP O COUNTY-AGENCY [�] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE Gi PHONE#WITH AREA CODE <br /> 4u rCA— ! l fes/ <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box0 micab E__1 INDIVIDUAL I1 LOCAL-AGENCY [=1 STATE-AGENCY <br /> L_j CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO L - � <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Eox bi�Itlka16 F7 1 SELF-INSURED 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY SONO <br /> O 5 LETTER OF CREDIT 6 EXEMPTION Ll W OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II. III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAM E(PR IN TEO&&GNATU RE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURIiDICTION# FACT d7LE/Z <br /> LOCATION CODE -OPTIONAL ICENSUS TRACT#_-9PTIONAL SUPVISOR-DISTRICT Ca-OPTIONAL <br /> Z 72,ML 10 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> `' FORa633AA6 <br />